Pessimism and failure in 6-part stories:



Pessimism and failure in 6-part stories:

Indicators of Borderline Personality Disorder?

Kim Dent-Brown1 and Michael Wang2

1University of Sheffield, UK & Hull and East Riding Community HealthHumber Mental Health NHS Teaching Trust.

2University of Hull, UK.

The work in this article was carried out in the Psychotherapy Department, Hull & East Riding Community Health NHS Trust, Miranda House, Gladstone Street, HULL HU13 0BB, United Kingdom.

Email address: K.Dent-Brown@sheffield.ac.uk (K. Dent-Brown)

First author’s contact details:

Address: Dr Kim Dent-Brown

Postdoctoral Research Fellow in Psychological Therapies

ScHARR, University of Sheffield

Regent Court, 30 Regent Street

SHEFFIELD S1 4DA

UNITED KINGDOM

Phone: +44 1482 640578

Mobile (preferred): +44 7904 456031

Fax: +44 1482 617501

KEYWORDS: Storymaking, 6-Part Story, projective tool, validation and reliability, personality disorder, depression, dramatherapy.

This article has been published as: Dent-Brown, K. and Wang, M. (2004). Pessimism and failure in 6-part stories: indicators of borderline personality disorder? The Arts in Psychotherapy 31(5): 321-333.

The 6-Part Story Method (6PSM)

The 6PSM is a dramatherapy tool that is frequently mentioned in the literature (Landy, Luck, Conner, & McMullian, 2003; Pendzik, 2003) and is taught in many dramatherapy training programmes. It has been described fully by its originators (Lahad, 1992; Lahad & Ayalon, 1993), but in brief it is a projective tool in which the client creates a fictional story following structured instructions from the therapist. The six parts of the story are:

1. A main character (who need not be human) in his or her setting

2. A task for the main character

3. Things that hinder the main character

4. Things that help the main character

5. The main action or climax of the story

6. What follows from the main action

The participant draws simple images on a sheet of paper as the instructions are given, to act as a prompt when the story is told. Once the six pictures are drawn the participant is asked to tell the story, without interruption or questions. They are to tell it in as full and detailed a way as possible, adding detail and inventing new descriptions as they go. Finally, the clinician or researcher asks questions about each picture and the story in general, to elaborate the story and check any points that are not clear.

The two publications by Lahad make implicit claims about the validity of the method in several places: “My assumption is that by telling a projected story based on the elements of fairytale or myth, I may be able to see the way the self projects itself in organised reality in order to meet the world.” (Lahad, 1992 p.157); “So, it seems that with the aid of the structured story, a person’s coping resources and conflict areas can be located relatively quickly.” (Lahad & Ayalon, 1993 p.18).

Lahad notes the many criticisms levelled against projective techniques, listing seven areas of concern including the lack of standardised administration instructions and the concerns about low validity and reliability. However he says: “Most of the above [concerns] are less evident in the 6PSM because of its nature and the way it is administered. Reliability is problematic, whether inter-measurement (i.e. between projective techniques of other kinds) or with different judges.” (Lahad & Ayalon, 1993, p.24).

Since the publication of these descriptions of the 6PSM, the method has become one of the standard methods of assessment in dramatherapy, often referred to in the professional literature. For example Landy et al. (2003) make reference to the 6PSM in their literature review of dramatherapy assessment instruments, as does Pendzik (2003). However neither author, nor Lahad himself, makes any reference to studies of the reliability and validity of the method.

Subsequent published accounts of the use of the 6PSM (Dent-Brown, 1999a, 1999b, 2001b) have described its use in a National Health Service (NHS) personality disorder service. These articles take for granted that the data produced by the 6PSM can be relied upon as a replicable and valid indicator of the story-teller’s personality. This assumption may be necessary in the building of a technique, which must be developed and found to be clinically feasible and useful in the first place. But although necessary, this assumption alone cannot be sufficient if a technique is to be regularly used for clinical decision making. It was for this reason that this reliability and validity study of the 6PSM was planned.

Historical Development of the 6PSM

The 6PSM has its roots in the early 20th century morphological study of fairy tales and the later semiological studies that followed. The morphological studies followed a tradition stemming from folklore studies or anthropology, in simply listing and classifying story elements. The later semiological studies concentrated on the study of human communication using formal sign systems such as spoken or written words. Their focus was on how meaning emerges, and on how the ‘signifiers’ (such as vocal sounds or marks on paper) are connected to the ‘signified’ (the objects or concepts referred to ). In both disciplines the search was for general, universal factors that were common to particular, individual stories.

Early in the 20th century the greatest contribution came from Vladimir Propp (1968) whose study The Morphology of the Folktale was originally published in Russian in 1928. Propp was interested in common themes running through the extensive canon of Russian fairy tales, and he produced a list of dramatis personae such as the hero, the dispatcher (who gives the hero the task), the villain (who opposes the hero) and the provider (who gives things that help the hero).. Although neither every actor nor every element appeared in every story, he believed that he had identified a sequence of events and characters that always appeared in a certain order.

So far this analysis was restricted to the very circumscribed genre of Russian fairy tales. In the 1950s French structuralists and semioticians took great interest in Propp’s work, starting with Lucien Tesnière (1959) who looked at the dramatis personae and came up with the concept of the actant. He defined actants as: “…beings or things that participate in the process (of the story) in any way whatsoever, even as mere walk-on parts or in the most passive way.1”

This helpful definition moves the focus wider than just people. Tesnière makes it clear that animals and even inanimate objects can be actants; for example a story about a prisoner in a cell seems only to have one actor, the prisoner struggling for freedom. But there are two actants; the cell that confines the prisoner is just as much a part of the story as the prisoner him or herself.

Subsequently Algirdas Greimas (1966) used Tesnière’s concept of actants to codify Propp’s dramatis personae, simplifying them into a system of six actants set out in Figure 1 below:

Figure 1: Functional organisation of Greimas’s six actants

Greimas considered that this structure might describe all stories, not just Propp’s large, but specialised, body of fairy stories. The core of the story is the subject-object pair, or what might be seen as the hero and their task.

Alida Gersie and the development of Story Evocation Techniques

In his introduction to the 2nd edition of Propp’s Morphology, Alan Dundes makes some suggestions (1968, p.xv) about the implications of Propp’s (and by extension Greimas’s) findings. He suggests the construction of story stems as prompts to see how children respond, saying that ‘”such a test might also be of value in studies of child psychology”(p.xv). He also suggested that “Propp’s scheme could also be used to generate new tales”; a suggestion noted and taken up subsequently by Alida Gersie.

Gersie is an Anglo-Dutch dramatherapist who has published extensively on the therapeutic use of stories (Gersie, 1991, 1992, 1997; Gersie & King, 1990) and who has been teaching and supervising dramatherapists and others in the use of story since the late 1970s. She developed methods that helped a client create a new story, which she called Story Evocation Techniques (SETs). These were question-based techniques where the participant would be asked open questions to establish the framework of the story on which they would then elaborate. These SETs were taught to other dramatherapists but had not been written about in detail until more recently (Gersie, 2002, 2003a, 2003b).

Two of the therapists who were taught by Gersie in the early 1980s were Mooli Lahad and Ofra Ayalon. Lahad was an educational psychologist and dramatherapist working in the educational system in northern Israel, while Ayalon was a child and adolescent psychotherapist working nearby. Lahad worked in northern Galilee, a strip of Israeli territory that was subject to frequent attacks from neighbouring Lebanon and Syria. He was working with schools to develop pupils’ resilience to trauma, and developed the SET he had been taught into the 6-part story method (Lahad, personal communication, 15/11/99). The point of the 6PSM was not that the storymaking should in itself be therapeutic, but that the coping elements in the story might give insight into the preferred coping strategies of their authors (Lahad, 1992; Lahad & Ayalon, 1993). The 6PSM has since become widely used in Israel, in settings and for purposes as diverse as personnel selection in education and to monitor the emotional wellbeing of children in a paediatric oncology ward (Dent-Brown, 2001a).

In the 1990s Lahad travelled frequently to the UK to deliver training, and the 6PSM was taught by him to a new generation of dramatherapists and others. Subsequently it has become a standard part of the syllabus of pre-registration dramatherapy courses in the UK. The 6PSM was adopted as part of a wider patient assessment package in an NHS personality disorder service (Dunn & Parry, 1997) with a view to the 6PSM triangulating with self-report and clinical interview to maximise the information gained from patients (Dent-Brown, 1999a). This use of the 6PSM has generated much interest (Dent-Brown, 1999b) but a lengthy search found no publications reporting the results of empirical research into the technique.

Method

Participants

Twenty-four clinicians were recruited from the Community Mental Health Teams (CMHTs) of an NHS Trust in the United Kingdom. Most were mental health nurses but other professions included occupational therapy and clinical psychology. These clinician participants in turn recruited patient participants from among their caseloads. Patient participants were receiving mental health treatment as outpatients, were aged between 18 and 65 and were not suffering from a psychotic illness. Eleven of the 25 patients recruited had a diagnosis of borderline personality disorder (BPD), while 12 of the 25 did not have such a diagnosis. (Two of the patients declined to undertake the interview necessary to make the diagnosis.) Suitable patients to approach were selected randomly from the caseloads of the clinicians involved.

Measures

Once recruited, the first author trained the clinician participants in the administration of the 6PSM. This training took approximately two hours and was conducted in small groups, as a part of which every clinician created and told a 6-part story of their own. These stories were audio-taped by the researcher. The clinicians then undertook an audio-taped 6PSM session with the patient/s whom they had recruited, followed by a second session one month after the first to record a second story. In order that the instructions given to both clinicians and patients were the same, a script was developed for the administration of the 6PSM and the subsequent questioning.

Between the two 6-part story sessions, patient participants were interviewed by the first author and concurrent clinical measures obtained. These included the SCID-II (First, Gibbon, Spitzer, Williams, & Benjamin, 1997) and the CORE-OM (Evans et al., 2002).

Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II)

The SCID-II is a clinical interview which aims to provide a complete assessment of all the criteria for every one of the DSM-IV Axis II personality disorders. It starts with a 119-item self-report questionnaire, and the subsequent interview concentrates only on those items endorsed positively by the participant – for example “Have you tried to hurt or kill yourself or threatened to do so.” The participant may have said yes to this, but the interview clarifies whether or not this has taken place on several occasions, and whether it has occurred outside the context of a depressive illness; only these conditions would meet the criterion for Borderline Personality Disorder. The result of the SCID-II is a count of the number of criteria met for each personality disorder, and a categorical (present/absent) diagnosis for each.

Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM)

The CORE-OM is a 34-item self-report questionnaire developed in the UK as a general outcome measure for counselling and psychotherapy. It has four sub-scales for Problems, Well-being, Functioning and Risk to self and others. Normative data provided (Evans et al., 2002) gives cut-off points for each scale between clinical and non-clinical populations, and the instrument has been shown to have good discriminant properties between such groups and to be sensitive to change. The 34 items are endorsed on a 0-4 Likert scale, and the global and sub-scale scores are expressed as mean scores with the same 0-4 range. Examples of questions from the CORE-OM include “Talking to people has felt too much for me” (Function sub-scale) and “I have felt despairing or hopeless” (Problems subscale).

The 6-Part Story Method

Story tapes from clinician and patient participants were transcribed and sent to a panel of raters. These raters had previously been trained by the first author in a similar way to the clinicians in the study, but all raters were blind as to the authorship of the stories they received. Raters were asked to read each transcript and to rate a set of statements about the story. The statements used had been shown to have adequate inter-rater and test-retest reliability (Dent-Brown & Wang, in press).

Results

Development of a pessimism/failure scale

A set of statements was identified by factor analysis that distinguished between stories from participants with and without a BPD diagnosis. Six statements from a pool of 26 made up this distinguishing set (Dent-Brown & Wang, in press). Three statements were more frequently true of stories from patients who did have a diagnosis of BPD:

• The story as a whole seems to be pessimistic or negative

• The whole atmosphere of this story is barren, bleak and lonely

• Morbid themes of death, aggression, pain or decay predominate

While three statements were more frequently true of stories from patients without a BPD diagnosis:

• The outcome is a ‘win-win’ situation for the main character and most others

• The outcome is positive for the main character

• Positive images of life, growth, health or production predominate

These six statements were assembled into a scale, which was given the name of the pessimism/failure scale (PF scale). The mean PF scores of the three groups were compared and there was a significant difference between the scores from the group of patients with a BPD diagnosis and the other two groups (patients without a BPD diagnosis and clinicians) combined (t = -4.50, df = 59, p .05).

The factor analysis of statements describing stories also suggested two other scales with acceptable inter-rater reliability, one relating to the presence or absence of helpful others in the story, and a second relating to the degree of violence or aggression described in the story. However, although these factors could be rated reliably by different raters (as with the PF scale), they were not stable when two stories recorded at different times from the same individuals were compared. It can reasonably be assumed that personality disorder status is not going to vary on a month-to-month basis, so if these two scales were measuring anything it was more likely to be a transient state perhaps related to life events or Axis I problems, and not stable traits or Axis II personality difficulties. The PF scale was stable across the two stories recorded one month apart, and may therefore be genuinely related to personality or some other more stable characteristic.

Influence of depression on the PF scale

With the emergence of this strong theme of pessimism and failure, the possibility arose that this was linked to participants’ possible depressive illness rather than their personality. To investigate whether the level of depression of the storyteller had an effect on the pessimism/failure scores of their stories it was necessary to use a proxy measure. No measure of depression had been taken as part of the measures given to participants, but a recent study has demonstrated that scores on the Beck Depression Inventory (BDI) can be inferred from patients’ CORE scores (Leach, Lucock, Barkham, Noble, & Iveson, in preparation). Translation tables from this study were used to estimate the BDI score of all the patient participants.

The degree of depression of a story’s author was positively correlated with the pessimism/failure score assigned to their story by raters (correlation = .50, p ................
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